CCS Patient Assessment & Documentation 3 — Questions and Answers
Question 1: Which auscultatory finding is best described as a high-pitched, scratchy sound heard best at the left sternal border with the patient leaning forward?
- Pericardial friction rub (Correct answer)
- Pleural friction rub
- S4 gallop
- Aortic stenosis murmur
Correct answer: Pericardial friction rub
A pericardial friction rub is a pathognomonic sign of pericarditis, heard as a scratchy, leathery sound at the left sternal border.
Question 2: A 65-year-old patient with a history of CAD rates chest pain as 7/10 with diaphoresis and radiation to the left jaw. The MOST urgent documentation action is:
- Document time of symptom onset and notify the provider immediately (Correct answer)
- Complete the full nursing assessment before notifying
- Document and wait for the next scheduled vitals check
- Record symptoms and administer PRN acetaminophen
Correct answer: Document time of symptom onset and notify the provider immediately
Time of symptom onset is critical for reperfusion decision-making in ACS; immediate provider notification follows per STEMI protocols.
Question 3: The New York Heart Association (NYHA) Classification places a patient who is comfortable at rest but experiences symptoms with less than ordinary activity in which class?
- Class III (Correct answer)
- Class I
- Class II
- Class IV
Correct answer: Class III
NYHA Class III describes marked limitation of physical activity, with symptoms occurring with less-than-ordinary effort but comfort at rest.
Question 4: When assessing peripheral pulses in a patient with suspected peripheral arterial disease, which scale is used to document pulse quality?
- 0 to 4+ scale (Correct answer)
- 1 to 10 numeric scale
- A to D grading system
- Weak/moderate/strong descriptive scale
Correct answer: 0 to 4+ scale
Peripheral pulses are graded on a 0 to 4+ scale where 0 = absent, 1+ = diminished, 2+ = normal, 3+ = bounding, and 4+ = aneurysmal.
Question 5: A patient's ankle-brachial index (ABI) is documented as 0.55. What does this value indicate?
- Severe peripheral arterial disease (Correct answer)
- Normal arterial perfusion
- Mild peripheral arterial disease
- Non-compressible vessels
Correct answer: Severe peripheral arterial disease
An ABI of 0.55 (below 0.70) indicates severe PAD with significantly reduced arterial flow to the lower extremities.
Question 6: Which element must be documented in the patient record before a transesophageal echocardiogram (TEE) can be performed?
- Written informed consent and NPO status (Correct answer)
- Chest X-ray within 24 hours
- Prior TTE within 30 days
- Creatinine level within 48 hours
Correct answer: Written informed consent and NPO status
TEE requires informed consent for the semi-invasive procedure and confirmation of NPO status to minimize aspiration risk during sedation.
Question 7: A CCS reviewing an ECG documents the PR interval as 0.24 seconds. This finding should be reported as:
- First-degree AV block (Correct answer)
- Second-degree AV block Mobitz I
- Normal sinus rhythm
- Third-degree AV block
Correct answer: First-degree AV block
A PR interval greater than 0.20 seconds (200 ms) defines first-degree AV block, indicating slowed conduction through the AV node.
CCS Patient Assessment & Documentation 3
Which auscultatory finding is best described as a high-pitched, scratchy sound heard best at the left sternal border with the patient leaning forward?